Learning how to do a proper history and physical serves as the foundation for training young physicians. This includes learning how to examine sensitive parts of the body. A rectal exam. A pelvic exam.
When I was training, paid models served as teachers when we learned how to do a pelvic exam. They had done this before. They provided feedback. They knew what they were getting into.
Fast forward to today. An article in the journal Bioethics noted that educational pelvic exams are often performed on anesthetized women. The frequency of such practice is unknown.
The author quoted one male medical student:
In obstetrics and gynecology, I encountered the first act of medical training that left me ashamed. For 3 weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women, without specific consent, solely for the purpose of my education. Typically, this would unfold as follows: I would be assigned a gynecologic surgery case on which to scrub in. I would be required to go meet the patient beforehand and introduce myself as ‘the medical student on the team’ or some such vague statement of my role in the procedure, without mentioning a pelvic examination. I then would follow the patient into surgery. Once anesthesia was administered and the patient was asleep, the attending or resident would ask me to perform a pelvic examination on the patient for educational purposes. To my shame, I obeyed. As a medical student, I am all too aware of the hierarchy that exists during training. My medical education experience has reinforced the notion that the medical student should not question the practices of those above him or her. I was very conflicted about performing an act that I felt was unethical, but owing to both the culture of medicine and my own lack of courage, I did not immediately speak out against what I was asked to do by residents and attendings.
Four states (Hawaii, California, Illinois, and Virginia) have made the practice of nonconsensual pelvic examinations under anesthesia illegal.
Just how common is the practice?
In 2003, Ubel1 et al. surveyed 400 medical students from five medical schools in Philadelphia, 90% of whom admitted to having performed a pelvic exam on an anesthetized woman, although it was not clear how many of the women had consented to the exam. A similar survey at the University of Oklahoma in 2005 found that a large majority of medical students had given pelvic exams to gynecologic surgery patients who were under anesthesia, and that in nearly three quarters of these cases the women had not consented to the exam. Coldicott et al.2 published findings from a medical school in the United Kingdom in which students anonymously reported that at least 24% of intimate examinations they performed on anesthetized patients occurred without any consent and that ‘on many occasions, more than one student examined the same patient’.
Not uncommon at all.
The topic has kindled hot debate on studentdoctor.net, a popular forum for medical students. The majority of participants conclude the practice is necessary for training medical students.
It’s suprising [sic] how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We’re about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation! If you get into this habit of being deathly afraid of the patient’s feelings about an internal exam you will never learn how. I’m not saying that you should be a jerk about it, but you owe it to your future patients to get some idea of what stuff feels like.
A typical counterargument reads:
I am cringing a little at this thread. As a female student not yet in the medical field, I am disturbed to hear that by consenting to surgery, I risk having someone literally in my vagina without consent for purposes that benefit only the providers, and not me. Are patients really viewed as a teaching tool rather than a human being? That I will be splayed and sliced during the procedure doesn’t mean that additional indignities are acceptable. It’s still my vagina, even if I am naked and unconscious. I didn’t lend it to anyone to practice techniques.
One reason attendings do not secure consent from the patient for an educational exam is the unconscious concern the patient would say no. If so, then failure to obtain consent is willful blindness.
And all the more reason to obtain consent.
When studied, it turns out many women are willing to assist in a student’s education and provide consent.
A survey in Canada found that the majority of women (62%) report that they would agree to have a pelvic examination performed on them by a medical student while they are under anesthetic, while 5% say they would consent only if the student was female, 18% are not sure, and only 14% say they would refuse. A study in Ireland tracked the number of women who agreed to having a pelvic exam performed by a medical student while they were unconscious and found that 74% consented and only 26% refused. Relatedly, the vast majority of patients receiving outpatient obstetric–gynecologic care agree to have medical students participate in care, with Berry et al. reporting rates of 79–86% and Ching et al. reporting 89% during obstetric visits and 81% during gynecologic visits. This suggests that the benefits to be gained from educational pelvic exams would not be significantly compromised by a requirement of consent.3
One argument that some physicians make is that performing a pelvic exam is not dissimilar to examining any other organ. In other words, no big deal. This is called “Is the vagina different from the mouth argument?”.
As medical doctors, and especially as gynecologists, we are trained to see the genital organs as part of the entire human anatomy, and examination of the patient’s genitalia should not elicit any feeling other than medical rationale. Therefore, when Dr. Barnes found that his friends outside the medical field were ‘shocked and horrified’ when knowing that medical students perform supervised pelvic examination on patients under anesthesia, he should not be surprised. I assume that fourth‐year medical students see the genitals of patients in a professional way, without the taboo and different feeling elicited in the general population.
Perhaps.
But consent is generally construed from the perspective of the patient, not the attitude of the doctor performing the examination.
So, what to do?
If it is true that the majority of patients would consent to a pelvic examination under anesthesia, obtaining consent brings the patient into the calculus. And there should be no shortage of subjects who would volunteer.
Alternatively or in parallel, why not continue to have paid models teach? They are awake and provide feedback, enhancing the educational experience. There, consent is explicit.
Taking consent to the other side of the spectrum, some argue that even performing an unconsented percussion of a liver while the patient is anesthetized amounts to a legal faux pas. Battery. Their argument continues noting that performing a pelvic exam and percussing a liver both require consent. Technically, this argument might be correct, though consent for what the vast majority view as trivial will likely raise no eyebrows. The public treats examination of genitals as being more sensitive, more intimate, and requiring additional layers of protection.
My take on consent for educational pelvic examinations (and rectal examinations): ask before you examine.
What do you think?
1 Ubel, P. A., Jepson, C., & Silver‐Isenstadt, A. (2003). Don’t ask, don’t tell: A change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. American Journal of Obstetrics and Gynecology, 188(2), 575
2 Coldicott, Y., Pope, C., & Roberts, C. (2003). The ethics of intimate examinations–teaching tomorrow’s doctors. (Education and debate). British Medical Journal, 326(7380), 97.
3 Berry, R. E., Jr., O’Dell, K., Meyer, B. A., & Purwono, U. (2003). Obtaining patient permission for student participation in obstetric‐gynecologic outpatient visits: A randomized controlled trial. American Journal of Obstetrics and Gynecology, 189(3), 634–638; Ching, S. L., Gates, E. A., & Robertson, P. A. (2000). Factors influencing obstetric and gynecologic patients’ decisions toward medical student involvement in the outpatient setting. American Journal of Obstetrics and Gynecology, 182(6), 1429–1432. https://doi.org/10.1067/mob.2000.106133
ABOUT THE AUTHOR
Jeffrey Segal, MD, JD
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
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I find this practice problematic because if it is not relevant to the surgery why is the exam being done. Also, the lack of discussion and informed consent strikes me as being a troubling issue. Also, I wonder if medical battery is an applicable concept absent medical justification and adequate consent. Medical student education should not be used as a reason to usurp patient autonomy and the requirement of informed consent. I learned to do these procedures on awake patients supervised by physicians after the patient was apprised of the situation and verbally consented to the experience. And I am sorry but the genitals are treated differently! I do not see lawsuits filed over allegations of inappropriate examination of my ears or ingrown toenails.
Ask before you examine!
Wow, I think this is horrible. I trained from 1989 to 1993 and we had no problem finding women to consent to pelvic exams while awake in clinics with our attending present. I am ashamed of the above mentioned medical schools who are abusing these women. Thank you for the article Jeff.
We had paid patient models that were awake for us to learn gyn and urologic exams. When asked why they volunteered, some said that were graduate students at he university and needed the money. Others said that they had a poor experience as a patient and wanted to help train new physicians to have the proper respect for patients. The training was done in groups under supervision of an attending. We had to come in introduce ourselves and get acquainted with the model patient. I think that this was an excellent way to train because we could get immediate feedback on if we were causing pain etc. and also learned the proper comportment.
I trained 1977-81. We had paid models who understood OUR embarrassment! Hell, mine helped me find her ovary and we all appreciated the immediate feedback they offered. I see no real reason not to get consent.
I trained from 1976-80. Our paid models were senior nurses, usually with strong educational backgrounds. They knew what we were doing even if we did not. It was excellent training. I would not support pelvic exams under anesthesia without consent. I see potential liability there.
Is it unethical to allow a medical student to feel gallstones during a laparotomy? Or to palpate a uterine fibroid? Or feel the pulsations in an abdominal aortic aneurysm? Medical students will soon be confined to mastery of the EMR.
Our gyn training was on awake patients. So we never got into the issue of anesthetized versus non anesthetized debate.
However, I attended a medical school overseas in the third world and the concept of not having a medical student and resident there to assist was unheard of. Patients were grateful for the extra attention that they received from us even though we were in training in all fields. They were happy to be at a university teaching hospital. They were happy to be receiving medical care of any kind that would relieve them of their suffering, discomfort, pain or illness.
As a surgical resident on a plastic surgery rotation, the plastic surgeon with patient consent allowed us to examine a breast that had an implant versus one that did not (same patient). The patient was thrilled that we as residents could not tell the difference between the breast that was implanted versus the one that was not. The plastic surgeon was that good.
We had “models” as well – the male had a varicocele. If a female patient requires GYN surgery, any med stud who would take objection to performing an instructed pelvic exam should not have gone into medicine.